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Case Report

Case Report. No.1Respiratory Ward. General. Patient : Weiwei Female 53ys Han nationality Profession : Retired chemical plant worker chief complaint : Cough, hemoptysis for 1 month Height: 163 cm Weight: 97 KG. HPC (history of present illness).

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Case Report

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  1. Case Report No.1Respiratory Ward

  2. General • Patient : Weiwei • Female 53ys Han nationality • Profession: Retired chemical plant worker • chief complaint : Cough, hemoptysis for 1 month • Height: 163cm Weight: 97KG

  3. HPC (history of present illness) • Onset: A month ago, the patient coughed up bright red bloody sputum in the morning, several times a day; sometimes it happened in the afternoon. She had no fever or shivering, no chest distress or dyspnea, no night sweat, no emaciation, no hypodynamia, no hematuria or any other discomfort. Then she turned to Changhai Hosptial, the chest CT showed：two-lung multiple nodules shadow, but she did not receive any treatment at that time. In order to seek further diagnosis and treatment, she was admitted to our ward on 2011-07-18 .

  4. Past history • hypertension history for 10 years • diabetes mellitus history for 10 years. • Denied the clear previous medical history like: coronary heart disease,tuberculosis and so on. • Surgical history: operation for lumbar disc protrusion • Drug allergy history: Penicillin allergy • Personal history: Denied smoking and drinking, father died of lung cancer, mother died of pancreatic cancer

  5. Physical examination on Admission • T:36.6℃,P:82b/m,R:20b/m,BP:155/90mmhg, • Obesity • Superficial lymph nodes were impalpable • No skin rash or petechia • Coarse breath sounds in both lungs,and no significant dry and wet rales • Rhythm of the heart :82b/m, tidy, heart sounded low, P2<A2,no pathological murmur. • extremities activity, no clubbed finger

  6. Laboratory test(7-19): • routine blood test :WBC:9.0*10^9/L N50.20% EOS 0.13*10 ^9/L PLT 278*10^9L • Dung conventional test :negative ；routine urine test ：WBC3+quantity 71/u, erythrocyte 20/ul • Blood coagulation :PT:9.4S INR:0.88R FIB:5.0g/l DDimer :200ng/ml • Blood biochemical tests:normal、SACE(-) • GLU 6.5mmol/L，2H blood sugar 12.1mmol/L after meal • HIV/syphilis、Two pairs of semi-hepatitis B :negative • Tumor Marker :normal

  7. Laboratory test(7-19): • Mycoplasma, chlamydia, legionella antibody: negative； • G test:negative；ESR:24mm/h ;CD4/CD8:1.98 • Blood allergy screening:total IgE 100-200Iu/L, MX1 1.09IU/L • Full rheumatic antibody test、Rheumatoid factor、O antibody、Tuberculosis antibody: negative • Arterial blood gas analysis：PaO2-93mmHg PaCO2-39mmHg; • Sputum bacteria 、Fungal culture:negative; sputumtuberculosis smear ： negative *2； • Sputum Liquid-based cytology test:negative *3

  8. auxiliary examination • electrocardiogram ：normal • Pulmonary function test：pulmonary ventilation function 、Pulmonary residual volume and Total ratio 、diffusion function is normal；Airway Resistance increased ； • Abdominal ultrasound ：fatty liver • Breast ultrasound ：noamal • Neck by color Doppler ultrasound ： the lymph nodeswere seen on the right side of the neck, about 12*4mm; Left neck 、Thyroid 、Parathyroid glands showed no significant abnormality

  9. auxiliary examination • Chest enhanced CT: Two nodular masses were seen in the lower lobe of the left lung，and a small nodules were found in the right upper lobe posterior segment，some inflammation of the right lung lower lobe was found. • lung MIBI： Abnormal uptake lesions in the Right lung Ueno • bone ECT： negative； • Brain CT： Both sides of the basal ganglia lacunars infarction； • abdominal CT： Ingot into the lumbar，the rest is not seen obvious abnormality； • Electronic bronchoscope:negative ； • Bronchial brushing cancer cells 、Liquid-based： negative ；

  10. Chest CT film 2011-03-02

  11. Chest CT film

  12. Chest CT film

  13. Chest CT film

  14. Chest CT film

  15. Chest CT film

  16. Admission diagnosis: • Lung nodules:Lung Cancer? Metastasis？ • Pulmonary infection • Type 2 Diabetes Mellitus • Hypertension

  17. The Purpose of Discuss • Diagnosis?

  18. Differential Diagnosis • Sarcoidosis： Multi-system organ involvement granuloma disease. Often violated lung,Bilateral pulmonary hilar lymph nodes or meditational lymph nodes ,skin,eyesand superficial lymph nodes • Tuberculosis： More symptoms of TB， imaging of plaques, nodules cord shadow, sputum TB smear or culture, PPD can be positive • Fungal infections: there are many defects in host immune function, imaging can also be expressed as nodules, but the sputum fungal culture, GM experiments and other tests to help diagnose

  19. Follow-up • 2011-07-28 Change to Surgical ward； • 2011-08-02 Perform partial resection of the left lung lower lobe by VATS;

  20. Pathology

  21. Pathology

  22. The Final Diagnosis • Lung nodules: Pulmonary Sclerosing Hemangioma

  23. Pulmonary Sclerosing Hemangioma

  24. Background of Name • PSH is a kind of rare benign tumor of lung, which was firstly named by Liebowand Hubbellin 1956. There have been a lot of arguments about its histogenesis and clinical behavior.With the development of immunohistochemisty,more and more new antibody to be used, The hypothesis is that PSH cells originate from pulmonary epithelial instead of vascular endothelial, mesothelial and neuroendocrine cells. The PSH was categorized as a miscellaneous tumors in 1999 WHO classification of lung tumors.

  25. Origin of Tissue • Analysis the immunohistochemical performance of 100 cases of PSH, Devouassoux-Shisheboran and his colleagues found that the expression of the characteristic antigen EMA and CK in epithelial cells, was high, especially the TTF-1 (thyroid transcription factor-1) and SPB(surfactant protein). The expression of CEA and SAM (smooth muscle actin) is negative.These results prove that PSH cells originate from alveolar epithelial . A variety of epithelial cells develop these different levels, different directions of differentiation, accompanied by the proliferation or reaction of a variety of other ingredients.

  26. Clinical characteristics (1) • 13～76ys, the median age 46ys • Male and female ratio is about 1: 5，female easily Suffer from PSH is perhaps related to progesterone receptor • The patients are found in a routine medical examinationwithout obvious discomfort symptoms.

  27. Clinical characteristics（2） • The PSH patients haven’t positive signs, probably because of tumor’s shorter diameter and it’s position(lobar peripheral), seldom involved in  bronchus and blood vessels. • PSH can occur in any lobar,but most in right lung and in the middle or lower lobar. • PSH is usually diagnoed as a single nodule,but sometimes as multiple lesionsunilateral or bilateral lung.

  28. Treatment and prognosis • Surgery is the only effective treatment. • The choice of surgery :pulmonary wedge resection ,  segmentectomy of lung .if it’s hard to use wedge resection ,you would choose lobectomy. • Lymph node metastasis are rare and it’s  metastasis does not affect the prognosis. So lymph node dissection is not recommend. • PSH’s prognosis is good,There are the majority of patients with disease-free survival after operation.

  29. Summary • Pulmonary Sclerosing Hemangioma (PSH) has no obvious specificity in clinical symptoms and imaging findings. It's hard to diagnose before surgery. Make a definite diagnosis relying on pathology . Surgery is the only effective treatment. The choices of surgery have two: pulmonary wedge resection and  segmentectomy of lung. lymph node dissection is not recommended.

  30. Thank you！

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